Accidents direct causes

In the shorter case studies, only the immediate causes of the errors are described. However, the more extended examples in the latter part of the appendix illustrate two important points about accident causation. First, the precondihons for errors are often created by incorrect policies in areas such as training, procedures, systems of work, communications, or design. These "root causes" underlie many of the direct causes of errors which are described in this section. Second, the more comprehensive examples illustrate the fact that incidents almost always involve more than one cause. These issues will... 

Management and Policy Influences on Error and Accident Causation As has been emphasized in Chapters 1,2, and 3, the system-induced error view states that it is insufficient to consider only the direct causes of errors. The underlying organizational influences also need to be taken into accoimt. However, most of the available techniques stop when an immediate cause has been identified, such as less than adequate procedures or poor equipment design. The questions of why the procedures were poor, or why the equipment was badly designed, are rarely addressed at the level of policy. Kletz (1994a)... 

As discussed above, in a world with 4000 well-designed reactors, one would expect less than a 4% chance of a Chemobyl-scale reactor accident per century. If one estimates that such an accident might cause 20,000 eventual cancer deaths, the calculated risk over a century from reactor accidents would be of the order of 800 deaths. Reactors might do better or worse than this, but the anticipated scale of harm is in the ballpark of a thousand deaths per century - with large uncertainties in either direction,... 

To learn from the accident cases it is essential to indicate the type of incident which happened (e.g. explosion), the direct cause of the incident (e.g. static electricity), the reason why this could take place (e.g. filling through the gas phase) and finally - most important - the lesson how this can be avoided (e.g. fill the tank through the bottom). 

Similar remarks can be made about accident reports, it was observed that the focus of the majority is on the direct safety related deviations in the accident causation path, and almost no attention is given to the indirect safety related deviations. Indirect safety related deviations were mentioned but no attention was given to the fact that these deviations were in the causal path, re-occurring, and often present for a long time prior to the accident. Korvers (Korvers et al., 2002) gave some good examples by showing ten cases in which identical indirect safety related deviations present prior to accidents repeatedly caused similar accidents. 

Before the accident at least 6 safety mechanisms were disconnected to conduct experiments to increase the output of the reactor. This was the direct cause of the accident and as the power output surged from 7 to 50% in a few seconds there was a lost of coolant. The heat then melted the graphite rods used as a moderator. 

Politicians in our parliamentary democracies who wish to please public opinion feel the urge to take into account demands that are more emotional than scientific, and advocate restrictions even when these go against the best interests of the citizens. The Three Mile Island nuclear power plant accident in the United States which resulted in no fatalities, the more recent Chernobyl explosion which, as of 1988 had directly caused two deaths, have, with no good reason, prevented any resumption of the U.S. nuclear program and have aroused fears in European countries in people least likely to give way to mass hysteria. 

There have been numerous discussions about this accident, which produced the most casualties in the history of industrial disasters. Some arguments revolve around the direct cause of the accident. As is generally known, many major accidents have been caused by combinations of small accidents. The accident in Bhopal also happened as the result of a combination of serious mistakes the mixing of water with MIC caused by neglecting to put the metal sheet in place to separate reactive components, and the failures in operation of the exhaust gas scrubber and the flare stack. Such cases are frequently found where a safety device is temporarily removed because the device is troublesome. It is necessary to educate people that the reliability of a safety device should be tested and that the failure of a safety device can lead to unexpectedly terrible results. 

Of 13 deaths in which ecstasy was identified, three were determined to have resulted at least partly from ecstasy. Nine out of 10 cases in which ecstasy was present but was ruled as not having directly caused the death were due to gun shot wounds or motor vehicle accidents. There was one case of overdose with ecstasy and metamfetamine. In four of 10 cases, ecstasy concentrations were above the concentration associated with recreational use, but death... 

Chapter 2 examines the extensive literature which documents the high accident rate associated with new employees. Research on the relationship between job tenure and accidents, on the relationship between age and accidents, and on the relationship between employee turnover rates and accidents is reviewed. All of the research evidence points to safety issues associated with new employees. Smdies from around the world, and conducted in many different industries, have consistently shown higher accident rates associated with new employees. Furthermore, it is very likely that many of the accidents where the injured person is a senior employee (an individual that has worked for the organization for sometime) have in fact been directly caused by a new employee or by factors associated with new employees. Targeting new employee accidents is thus not only necessary to help reduce, and hopefully eliminate, accidents where new employees are injured, but should also help reduce the overall accident rate in an organization. 

The reliability of the mine hoist braking system, directly determines the safety of workers in the process of transportation. Relevant data show that coal mine safety accidents caused by the braking system failure account for over 60% of the total mine accidents, having caused great economic losses and casualties. 

According to the modem accident-causation (G. and B. et al., 2005), from the point of individual behavior-safety control, hazard is embodied unsafe act (behavior) and unsafe condition meanwhile, under certain situation, unsafe act (behavior) can transform and result in unsafe condition. The unsafe act and unsafe condition is the direct cause of accident, deeper analysis comes to the indirect (common) cause, which include three elements inadequate safety knowledge, inadequate safety awareness, and inadequate safety habit. 

People s unsafe behavior and unsafe state of object is the direct cause of accident, in which the unsafe behavior of the people is the most important reason, because most of the accidents are caused by human error. The key to create a safe atmosphere is to manage people, educate people, inspire people, and let the staff form strong safety awareness in the influence by environment, to achieve fundamental change from want me to be safe to I want security. ... 

Hong, Chen, et al. 2013. Characteristics of direct causes and human factors in major gas explosion accidents in Chinese coal mines Case study spanning the years 1980 010. Journal of Loss Prevention in the Process Industries 26 38—44. 

By the multidisciplinary theory and method of statistical analysis and case analysis, basic characteristics and rule of coal-gas dynamic disasters accidents in coal mines during 2001-2012 period were studied and the incentive control on ignition source of direct causes of gas explosion accidents were analyzed, so as to explore the approaches from the control of ignition sources for governance coal-gas dynamic disasters. 

ANALYSIS OF DIRECT CAUSES OF THE LARGER AND THE ABOVE DYNAMIC DISASTERS ACCIDENTS... 

Accident That is, accident is directly caused by human error, called A class accident. In such accidents, object and environment are in normal state . 

Based on the above analysis, the paper give a new definition for accidents category, that is. All coal mine accidents can be divided into 4 categories, that is, accident is directly caused by human error, we called it A class accident accident is caused by human error and object misconduct, we called it B class accident accident is caused by human error and environment degradation, we called it C class accident accident is caused by human error, object misconduct, environment degradation in the same time, we called it D class accident. So, we can say, human error is the ultimate reason of all accidents, and it is the essence of coal mine accident human error model. 

Heinrich summed up an important conclusion that the direct causes of accident are the... 

In all types of coalmine accidents, gas explosion occupied the largest share of the major accidents (Coal Mine Safety Supervision Bureau of the State 2012). Except by using engineering technology such as technical equipment or skills to prevent the gas explosion, understanding the law of the accident can also help the people to avoid repetitive accidents. Accident analysis results showed that nearly 100% of gas explosions are liability accidents, and the direct cause is unsafe act. 

This paper aimed to find the regularity of the direct cause of gas explosion, through the study of analysis of the generic unsafe act in the coalmine major gas explosion accidents based on the behavior based safety model, the following conclusions can be drawn ... 

The direct cause of the accident is unsafe acts. Therefore, preventing unsafe acts of employees and making them to complete the task by safe acts is particularly important. Mentioning unsafe behavior study and solutions BBS (Behavior-Based Safety) is mainly used abroad (LI Nai-wen JI Da-jiang 2011). The application of BBS method requires a longer time to build a safety culture... 

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